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Determine Medical Necessity

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Determine Medical Necessity

Review the drugs, devices, procedures, treatment plans, or other therapies and decide whether each is essential for addressing the patient or member's condition.

Required Editions

Available in: Lightning Experience

Available in: Enterprise and Unlimited Editions with Health Cloud

Medical necessity is a defining concept for all health plans, centered on delivering the right care. It refers to the drugs, services, or supplies that are required to appropriately and efficiently treat a specific medical condition.

Medical necessity decisions are made by the health plan's clinical professionals. Typically, decisions are made by a registered nurse, a pharmacist, or the health plan's medical directors, who are licensed physicians.

  1. In the Determination section, spell out the reason for approving or denying the request.
  2. Add notes for the benefit of other reviewers.
 
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